Rocky Mountain Health Plans recognizes that we cannot overcome the fragmentation that exists within the health and human services system, or achieve any of the three objectives in the Triple Aim, without community integration. This term, community integration, describes a whole-person approach to care coordination, in which all assets and services within a community are brought together in a comprehensive client centered structure that produces health. Rocky Mountain Health Plans believes the Accountable Care Collaborative framework, and the regional care collaborative organizations in particular, are uniquely positioned and resourced to create a comprehensive care coordination system that accounts for all key drivers of health.
Community care teams are a critical component of Rocky Mountain Health Plans’ integrated care coordination strategy. They provide support and expertise to clients and participating medical practices through direct services and care coordination, population management and quality improvement activities. Community care teams close gaps in resources, extend practice interventions within the community and work with clients in home and community settings to establish trusting, productive relationships. Community care teams also provide a focal point for local clinical and community leadership, build consensus among key stakeholders for a plan of targeted interventions; and implement interventions and evaluate their effect on the prevalence and impact on program goals.